Vision Coverage Grid

Vision Coverage Grid

Vision Care Services Co-Pay
Member Cost
Out-of-Network Allowance
Exam with Dilation as Necessary: $20 Co-pay Up to $35
Exam Options:
Standard Contact Lens Fit and Follow-up1
Premium contact Lens Fit and Follow-up2
Up to $55
10% off retail price
N/A
N/A
Frames:
Any available frame at provider location
$60 allowance, 20% off balance over $60 $30
Standard Plastic Lenses:
Single Vision
Bifocal
Trifocal
Lenticular
Progressive
$20 Co-pay
$20 Co-pay
$20 Co-pay
$20 Co-pay
$20 Co-pay
Up to $25
Up to $40
Up to $55
Up to $55
Up to $55
Lens Options:
UV Coating
Tint (Solid and Gradient)
Standard Scratch-Resistance
Standard Polycarbonate
Standard Anti-Reflective Coating Other Add-Ons and Services

$15
$15
$15
$40
$45
20% off retail price
N/A
N/A
N/A
N/A
N/A
N/A
Contact Lenses:
(Contact lens allowance covers materials only.)
a. Conventional
b. Disposable
c. Medically Necessary

a. $0 Co-pay, $90 allowance,
15% off balance over $90
b. $0 Co-pay, $90 allowance,
once every 12 months
c. $0 Co-pay, Paid-in-full

$72

$72

$200
Frequency:
Examination
Frames
Frame Lenses OR Contact Lenses
Once every 12 Months
Once every 12 Months
Once every 12 Months
LASIK and PRK Benefit:
Members receive 15% off retail price or 5% off promotional price for LASIK or PRK from the U.S. Laser Network, owned and operated by LCA Vision.
Continued Eyewear Savings: Your EyeMed benefit also provides for continued savings on additional eyewear purchases. After your initial benefits have been utilized, you are able to receive ongoing discounts on additional complete pair eyewear purchases at EyeMed provider locations, which result in discounts up to 40% off the retail price. See your EyeMed provider for details.
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Contact Lens By Mail Program
You may order replacement contact lenses for competitive prices via the internet, and have the contacts mailed directly to your home. The service is for replacement contact lenses only, and your core benefit allowance or discount will not apply to the service. Your initial pair of contact lenses must still be purchased from your eye care provider to ensure proper fit and follow-up care. Simply visit www.eyemedvisioncare.com for details, and a link to the order site.
  • Standard Contact Lens Fitting – spherical clear contact lenses in conventional wear and planned replacement (Examples include but not limited to disposable, frequent replacement, etc.)
  • Premium contact Lens Fitting – all lens designs, materials and specialty fittings other than Standard Contact Lenses (Examples include toric, multifocal, etc.)

Plan Limitations/Exclusions:

  • Orthoptic or vision training, subnormal vision aids, and any associated supplemental testing
  • Aniseikonic lenses
  • Medical and/or surgical treatment of the eye, eyes, or supportung structures
  • Services provided as a result of any Worker’s Compensation law
  • Corrective eyewear required by an employer as a condition of employment, and safety eyewear unless specifically covered under plan
  • Plano non-prescription lenses and non-prescription sunglasses (except for 20% discount)
  • Services or materials provided by any other group benefit providing for vision care
  • Benefit is not available on those frames where the manufactuer prohibits a discount
  • Standard Progressives are not available at all Provider locations.
Central Michigan University • 1200 S. Franklin St. • Mount Pleasant, Mich. 48859 • 989-774-4000